<!DOCTYPE html>
<html>
	<head>
		<meta charset="utf-8">
		<title></title>
		<script src="https://s3.pstatp.com/cdn/expire-1-M/jquery/3.1.1/jquery.min.js"></script>
		<script src="bootstrap-3.4.1/js/bootstrap.js"></script>
		<link href="bootstrap-3.4.1/css/bootstrap.css" rel="stylesheet" type="text/css" />

		<style>
			.table td {
			  vertical-align: middle !important;
			}
			.table label {
			  margin-bottom: 0;
			  vertical-align: middle;
			  float: left;
			}
			.table tr {
				height: 40px;
			}
			.table tr label {
				float: right;
			}
		</style>

	<body>
		<div class="" style="margin-bottom: 10px;">
			<table class="table table-bordered table-condensed">
				<tr style="background-color: lightgray;">
					<td colspan="6">基础数据</td>
				</tr>
				<tr>
					<td class="flex"><label>*姓名:</label></td>
					<td><input type="text" name="username" id="" class="form-control"></td>
					<td class="flex"><label>*身份证号:</label></td>
					<td><input type="text" name="idcard" id="" class="form-control"></td>
					<td class="flex"><label>手机号:</label></td>
					<td><input type="text" name="mobile" id="" class="form-control"></td>
				</tr>
				<tr>
					<td class="flex"><label>*年龄:</label></td>
					<td><input type="text" name="age" id="" class="form-control"></td>
					<td class="flex"><label>*性别:</label></td>
					<td><select class="form-control">
							<option value="0">男</option>
							<option value="0">女</option>
						</select></td>
					<td class="flex"><label>名族:</label></td>
					<td><select class="form-control">
							<option value="0">汉族</option>
							<option value="0">藏族</option>
						</select></td>
				</tr>
				<tr>
					<td class="flex"><label>*身高(cm):</label></td>
					<td><input type="text" name="age" id="" class="form-control"></td>
					<td class="flex"><label>*体重(kg):</label></td>
					<td><input type="text" name="age" id="" class="form-control"></td>
					<td class="flex"><label>BMI:</label></td>
					<td><input type="text" name="age" id="" class="form-control"></td>
				</tr>
				<tr>
					<td class="flex"><label>职业:</label></td>
					<td><input type="text" name="age" id="" class="form-control"></td>
					<td class="flex"><label>活动系数:</label></td>
					<td colspan="3"><select class="form-control">
							<option value="0">轻体力活动</option>
							<option value="1">中体力活动</option>
						</select></td>
				</tr>
				<tr style="background-color: lightgray;" class="flex">
					<td colspan="6">就诊信息</td>
				</tr>
				<tr>
					<td class="flex"><label>*就诊类型:</label></td>
					<td colspan="5"><select class="form-control">
							<option value="0">住院</option>
						</select></td>

				</tr>
				<tr>
					<td class="flex"><label>*入院科室:</label></td>
					<td><input type="text" name="age" id="" class="form-control"></td>
					<td class="flex"><label>主管医生:</label></td>
					<td><select class="form-control">
							<option value="0">张三</option>
							<option value="1">李四</option>
						</select></td>
					<td class="flex"><label>入院日期:</label></td>
					<td><input type="date" name="age" id="" class="form-control"></td>
				</tr>
				<tr>
					<td class="flex"><label>*住院号:</label></td>
					<td><input type="text" name="age" id="" class="form-control"></td>
					<td class="flex"><label>床号:</label></td>
					<td colspan="3"><input type="text" name="age" id="" class="form-control"></td>
				</tr>
				<tr style="background-color: lightgray;">
					<td colspan="6" class="flex">疾病信息</td>
				</tr>
				<tr>
					<td class="flex"><label>疾病诊断:</label></td>
					<td colspan="5"><textarea cols="28" rows="3" class="form-control"></textarea></td>

				</tr>
				<tr>
					<td class="flex"><label>其他诊断:</label></td>
					<td colspan="5"><textarea cols="28" rows="3" class="form-control"></textarea></td>
				</tr>
				<tr style="background-color: lightgray;">
					<td colspan="6" class="flex">病史摘要</td>
				</tr>
				<tr>
					<td class="flex"><label>陈述人:</label></td>
					<td><select class="form-control">
							<option value="0">本人</option>
						</select></td>
					<td class="flex"><label>可靠程度:</label></td>
					<td><select class="form-control">
							<option value="0">高</option>
							<option value="1">中</option>
							<option value="2">低</option>
						</select></td>
					<td class="flex"><label>记录时间:</label></td>
					<td><input type="date" name="age" id="" class="form-control"></td>
				</tr>
				<tr>
					<td class="flex"><label>其他诊断:</label></td>
					<td colspan="5"><textarea cols="28" rows="3" class="form-control"></textarea></td>
				</tr>

			</table>
			<div class="form-group" style="text-align: center;">
			    <div class="col-sm-12">
					<button class="btn btn-danger">取消</button>
					<button class="btn btn-primary">添加</button>
			    </div>
			  </div>
		</div>

	</body>
</html>